Lead Poisoning From Retained Bullets

Abstract

Lead intoxication (plumbism) from retained bullets has rarely been reported but may be fatal if unrecognized. Bullets lodged within joint spaces or pseudocysts are more likely to develop this complication, although patients with retained missiles in other locations may also be at risk. Subtle findings such as the occurrence of unexplained anemia, abdominal colic, nephropathy, or neurologic deterioration in patients with retained missiles may suggest consideration of plumbism. An intercurrent metabolic stress such as infection, endocrinopathy, or alcoholism may be a precipitating factor. Among the various diagnostic studies available, mass spectrometric stable isotope dilution analysis may be the most reliable. It is important to employ chelation therapy prior to any operative intervention. This will reduce the mobilization of lead from bone during or following the surgical procedure.

An EMG case report of lead neuropathy 19 years after a shotgun injury

“…The time interval from injury to onset of lead intoxication ranges from 3 days to 40 years. 9 Our patient was shot in the left elbow with multiple pellets surrounding the joint. It is speculated that the pellets gradually eroded into the joints over the years and finally resulted in systemic intoxication and lead neuropathy.…”

Elevation of Blood Lead Levels in Emergency Department Patients with Extra-articular Retained Missiles

“…WBL levels therefore represent a relatively short-term exposure to lead and do not reflect a patient's total lead burden. 3,12,22,26,27,[31][32][33][34][35][36] ZPP levels, in contrast, reflect the soft tissues' chronic burden of lead and are elevated at toxic concentrations. Lead interferes with the ability of protoporphyrin IX to fix iron for heme synthesis, resulting in a buildup of protoporphyrin levels.…”

“…Lead interferes with the ability of protoporphyrin IX to fix iron for heme synthesis, resulting in a buildup of protoporphyrin levels. 12,18,[32][33][34] However, the test for ZPP is not sufficiently sensitive to detect symptomatic patients at WBL concentrations below 25 g/dL, and so WBL levels remain the "gold standard" for diagnosing lead toxicity. 3,12,22,26,27,[31][32][33][34][35][36] As we expected some patients to have retained their missiles for more than 35 days, we obtained both WBL and ZPP levels.…”

“…13 Although inhalation and ingestion constitute the majority of lead exposures, implantation is a not uncommon source of lead toxicity. A computerized search of MEDLINE and a manual search of references found in review articles 6,9,12,21,23 revealed 88 publications that describe symptomatic lead poisoning from retained missiles. Most of these publications are case reports, with the earliest dating from 1867 23 and the most recent from 2001.…”

Posterior Wall Acetabular Osteotomy for Removal of a Juxta-Articular Bullet

“…These include mechanical blockade to movement, direct cartilage destruction, synovitis, joint sepsis, lead arthropathy and even systemic lead poisoning (plumbism) [1][2][3][4]. It is therefore recommended that all intra and juxta-articular bullets or bullet fragments should be removed.…”